Doctors’ bills play a role in 60 percent of personal-bankruptcy filings.

In April 2016, Venus Lockett was about to give a speech at an event she volunteered for near her home in Atlanta. She was already stressed. The previous night, she had stayed up late making her presentation, and then deleted it by mistake. As she stepped up to the podium to give her remarks, she noticed that her words were slurring. She tried to speak into the mic, but the words that came out didn’t make sense.

A friend walked up and grabbed Lockett by the arm. A few people, noticing something wasn’t right, walked Lockett to another room and called an ambulance. Lockett, who was 57 at the time and uninsured, didn’t know if she could or should refuse the ambulance ride or decide which hospital it should take her to.

Paramedics sped her a few miles to Emory University Hospital Midtown, where she was held overnight. It turned out she had suffered a transient ischemic attack, or a mini-stroke. The hospital performed tests and sent her home, where she recovered fully.

In May, the hospital bill arrived. Lockett was charged $26,203.62 total for “observation,” which the bill instructed her to pay within 20 days. Lockett went into a tailspin. “Dang, I knew I shouldn’t have gone to the hospital,” she remembers thinking. “But at the same time, that was really scary to me, not being able to talk.”

Lockett was about to join the ranks of Americans who live with crippling amounts of medical debt.

Medical debt is a uniquely American phenomenon, a burden that would be unfathomable in many other developed countries. According to a survey published this month in the American Journal of Public Health, nearly 60 percent of people who have filed for bankruptcy said a medical expense “very much” or “somewhat” contributed to their bankruptcy. That was more than the number who cited home foreclosure or student loans. (The survey respondents could choose multiple factors that contributed to their bankruptcy.)

The finding was only the latest in a long string of statistics suggesting that Americans who have faced major health scares often face significant financial setbacks afterward. A 2016 study found that a third of cancer survivors had gone into debt as a result of their medical expenses, and 3 percent had filed for bankruptcy. According to a Consumer Financial Protection Bureau study from 2014, medical bills are the most common cause of unpaid bills sent to collection agencies. About a fifth of Americans have a medical claim on their credit report, and the same proportion currently have a medical bill overdue.

“It’s just life,” says Deborah Thorne, a sociologist at the University of Idaho who co-authored the latest bankruptcy study. “It’s not like they’ve done anything wrong.”

Emergency rooms and planned surgical procedures are the most common causes of large medical bills that patients simply can’t afford to pay, advocates told me. Often, a hospital might be covered by a person’s insurance network, but the individual doctors who work there and the ambulance company that services it aren’t, a situation that can lead to something called balance billing. Sometimes, bizarre loopholes kick in at the darkest moments, like the fact that a baby would be covered upon birth under Medicaid or the Children’s Health Insurance Program, the government insurance program for children. But a stillbirth might not be covered, says Simon Sandoval-Moshenberg, a legal director at the Legal Aid Justice Center. (Indeed, one study found that average hospital costs for stillbirths are more than $750 higher than for live births.)

In some states, hospitals are required to provide charity care to certain low-income and uninsured patients, but several advocacy groups told me that these patients sometimes get regular bills instead. “We were seeing hospitals sending debtors to debt collections without saying anything to the debt collectors [about charity care],” says Emilia Morris, the legal director of Central California Legal Services. “The debt collectors are trying to collect these debts without making charity care available. The patient sometimes gets sued, gets a judgment entered against them, without ever having heard of charity care.”

In a statement, an American Hospital Association spokesperson told me that in 2017, hospitals provided more than $38 billion dollars worth of care to patients who could not afford it otherwise. “Hospitals across the country strive to find ways to help under- and uninsured patients navigate the health system,” the spokesperson said. “Hospitals offer charity care programs, check public assistance to see if the patient qualifies and provide discounts to these patients when possible. Every day, America’s hospitals treat patients who can make only minimal payment, or no payment at all.”

Still, some patients do wind up with medical debt, which discourages them from seeking medical care, because they fear they will incur even more debt if they go to the doctor again. The debt can also worsen peoples’ credit, which can make it hard for them to live healthier lives by, say, moving to better neighborhoods. In the end, they get sicker, and risk plunging even further into debt.

The $26,203 bill wasn’t the last one Lockett would receive from the incident that April. A separate bill, for two doctors’ consultations during Lockett’s hospital stay, came on April 28, for $1,301. (She provided this bill, along with the others, to The Atlantic for verification.) That amount was added to several more charges, for various x-rays and other diagnostic tests, for a new bill totaling $2,617 that arrived a month later.

Another bill, in May, came from Grady EMS, an ambulance service, for $1,807, for picking her up “from the scene,” as well as “mileage.” This bill encouraged her to leave her feedback in an online survey for the chance to win a $50 Kroger card. Lockett says she called the company to try to work out a deal, and a month later, Grady EMS sent her a new, reduced bill for $1,084. (Grady EMS did not respond to multiple requests for comment.)

Lockett’s attempts to negotiate with the hospital were less successful. On April 26, Lockett received a letter from Chamberlin Edmonds, a service that said it works with Emory Healthcare and claimed it could help her “find government benefits,” such as Medicaid or Medicare, to help pay her bill. This might have led to some confusion. Lockett says she didn’t have or qualify for either Medicare or Medicaid. (Georgia did not expand Medicaid under the Affordable Care Act, leaving about a quarter-million low-income adults in a so-called “Medicaid gap.”) But she thinks her first call upon receiving the bills was not to the hospital, but to Chamberlin Edmonds, which she incorrectly assumed could help bring down the overall hospital bill. (Chamberlin Edmonds’ website no longer exists, and the company that acquired it did not respond to requests for comment.)

Since Chamberlin Edmonds was only offering to help her find government insurance, for which Lockett did not qualify, the company wasn’t able to reduce her hospital bill or work out a payment plan. Lockett assumed this meant she was at a dead end with her nearly $30,000 in hospital bills. “They were saying that there was nothing that they could do,” she told me. She decided to put the bills aside and try to get to them after she found a job.

A year later, Lockett attended a meeting with representatives of Georgia Watch, a nonprofit group, as part of her volunteer work. When one of the Georgia Watch representatives mentioned that the organization has a guide for people who wish to negotiate down their hospital bills, Lockett grabbed a copy. She called the hospital back. This time, she says, they told her her entire bill had been wiped away.

Emory Healthcare said it could not comment on individual patients, but added that “patients will sometimes receive two bills for the same date of service: one bill for services rendered by the physician, the other for a hospital stay, supplies, services and equipment provided. Emory Healthcare’s customer service department works with patients to establish a mutually acceptable agreement for paying inpatient or outpatient bills.”

“The reality is that medical costs are not objective, real costs,” says Berneta L. Haynes, the director of equity and access at Georgia Watch. One day, an MRI can cost $19,000. The next, it can cost nothing.

Though she was still responsible for her reduced ambulance bill, Lockett was lucky. Others aren’t. Dana Peterman, a physical therapist in Forsyth, Georgia, owed more than $4,000, after insurance, when her son was rushed to the hospital with an anaphylactic peanut-allergy reaction in 2017. She tried to negotiate down her bill, but she says neither the hospital, nor the ambulance company, nor the ER doctors would give her a discount. She paid in full, not wanting the bills to affect her credit.

When negotiating with a hospital, consumer advocates I spoke with recommended asking about financial assistance, including charity care for the uninsured. If that fails, the patient can ask if they can pay whatever the hospital would have charged someone who was on Medicare—typically a lower rate. Hospitals and even collections agencies will often agree to payment plans, or a discount in exchange for a lump-sum payment.

Still, the current system requires people to independently negotiate on their own behalf with giant corporations over tens of thousands of dollars, often while recovering from a major illness. For those who haven’t done it before, the process can be confounding, as Lockett found. “Maybe I didn’t say the right thing before,” Lockett told me.

If the patient fails to pay, a medical debt might be sent to a debt collector. Some patient advocates say small medical debts are now getting sold to debt buyers, companies that try to collect as much as they can on long past-due debts. “Now we are seeing small-time medical practices get involved in selling their bad debts to debt buyers for pennies on the dollar,” says Sandoval-Moshenberg, of the Legal Aid Justice Center. Rather than medical records or a patient history, these buyers rely on little more than a list of debts in a spreadsheet, making it harder, Sandoval-Moshenberg and others argue, for patients negotiate a deal or expunge an error. But this practice makes financial sense for doctors, given how many people are unable to pay their bills.

When everything fails, and the person is at imminent risk of having their wages garnished because they’ve been sued for their medical debt, it might be time to file for bankruptcy, says Sandoval-Moshenberg. The people who do become the tip of a very big debt iceberg.

Olga Khazan is a staff writer at The Atlantic, which originally published this article.